I feel the tension of the psychiatric emergency room as soon as I enter. The chairs in the waiting area are full, and patients or family members are pacing in the spaces between the chairs and the registration desk. Some of those pacing stare at the staff room visible through the glass behind the desk. Others walk with downcast eyes as if memorizing the patterns on the floor. I slip by them and hang my coat on a hook in the back hallway and turn to the charge nurse who is walking toward me with a chart.

“This woman was brought in by the police. She tried to jump out of a three-story window. Her son and husband pulled her back in. Cantonese speaking, but I already called for an interpreter. Her son speaks English, so you can get started. Just get her admitted.”

Dramatic as it sounds, it’s an easier assignment than most. Usually, we’re handed a chart about a patient in crisis and no plan. The hard part of the job is sifting through the mess inherent in a crisis and formulating a plan. We are the city’s public hospital. Across the hall from our locked clinic is the city’s primary trauma center and medical emergency room. The entire hospital is a teaching facility for the medical school at the university across town.

I see the son right away. He is a tall and slender man-child. He looks as if his height is new, as if he is uncomfortable hovering over people. He has none of the usual swagger of teenage guys. He stands next to his mother, a short thick woman, who is sitting in one of the chairs weeping. The father, not as tall as his son but just as slender, is mumbling and pacing.

Two uniformed police officers, both of whom look to be in their thirties, are at the front desk. One is filling out a 5150, the form used to place the weeping woman on a seventy-two-hour hold. The other police officer is talking with the clerk. Margaret, a smart formidable African American woman, has worked in the clinic for ages. She does all the data entry and helps in managing the waiting area. She never gets rattled. She and the cop are smiling, not at all bothered by the activity that surrounds them.

I approach the mother and son and immediately the father is there. He’s yelling in Cantonese, not at me but at his wife. She cringes as if his words are pummeling her.

“Let’s go to a room,” I say to the boy. He leans down and talks softly to his mother as he takes her arm. The father follows, no longer yelling, but no less agitated. Along an interior wall we have four interview rooms. With the number of patients currently in the clinic, I am relieved that one is free. On a different hallway, there are also three seclusion rooms.

The room is eight by eight with white walls. The paint is not that old, but the walls are scraped and scuffed. Just like everything in this hospital. There is a large window that has lost its seal, so it looks perpetually dirty. Eventually it will come up on a maintenance list, and workers will appear and replace it. Along one wall is a cushioned bench that is the width of a single bed. It also serves as a couch. It is functional but uninviting. On the side wall is an old wood desk and a chair with wheels. Fluorescent lights burn overhead. The lights are more suitable for a medical emergency room than a place where calming patients is just as important as their medical status. The son and mother sit on the couch. The father, leaning against the wall, is scowling, but is no longer yelling. I sit at the desk and turn my chair to face the family. The interpreter arrives, introduces herself and takes a seat next to the mother on the couch.

I tell the son we plan to admit his mother to the hospital. He turns and speaks to his father. The father barks back at him and is gone from the room and from the clinic. I ask the interpreter to ask the patient if she wants her son to remain in the room. She is still sobbing but she puts her hand on his arm as she nods.

My questions are standard. I already know this woman is seriously depressed. Although she will not understand my words, I keep my voice calm and soft. It helps that we have treated her in the past and I can consult her old chart. Through the interpreter I tell the woman we are admitting her to the hospital, and she nods. Trying to reassure her, I say the unit where she will go has many Cantonese speaking staff. She nods again.

I focus on getting her history and current medical status. Although, on its face, it is likely she is presenting with an acute psychiatric crisis, I must be careful not to miss any medical problems that might have precipitated the crisis.

Once finished, I leave her in the room with her son, and I ask the doctor to write admission orders. I call the admitting unit and give the receiving nurse a report. Then we wait for an escort to take her upstairs. All this time the son has said nothing to me. Sitting next to his mother, he looks like he is all alone. My gut starts to ache for him.

Eventually transportation staff arrive and help the woman into a wheelchair. The son leans down and speaks to her. Then she is gone. The son stands to leave. I know where that ache in my gut is coming from now. Crossing every language and cultural barrier, this young man reminds me of my younger brother. At sixteen he was still living at home when my father declared bankruptcy. His need to help my parents was both visceral and resentful. Out of the house and immersed in my own life, I never showed up to do anything to help him.

“Sit for a minute?” I ask him. He starts talking before I say another word. “He is always yelling at her. At me too, but it’s her that worries me. I’m out of high school next year, but if I leave, I’m sure she’ll kill herself. I hate him, but I don’t know what to do.” I ask him a few more questions, are there other siblings, yes, but both are older, and they are not coming back. Do you plan to go to college? Yes, but I cannot leave her.

We sit in silence for a few minutes. I search for words, “It’s good that you want to take care of your mother.” And after a pause, I add, “You also have a right to a life of your own.”

Finally, I give him a slip of paper with the number for a clinic in the Chinese part of the city. “Maybe talking to someone will help.” He takes the paper and nods, then stands and slips it into his pocket. At the door he pauses, then turns to look at me and says, “Thank you.”

Months before I moved to this west coast city to go to graduate school. Having left a relationship that spanned ten years, I was single and thought a new start in a sophisticated city would energize me. Initially it felt like an adventure, but eventually I just felt alone and lonely. Arriving to a tight housing market, I stayed in a motel until I eventually found a studio apartment in a three-story art deco building. The neighborhood wasn’t pretty, but the studio was inexpensive, and the building’s locked front entrance and stony construction felt like a fortress.

Excited to have found a place, I hardly noticed the marginal nature of the streets around me. More industrial than residential, the streets bustled with commerce and lower working-class people scurrying to buses or walking their kids to school. But at night it became shaded, not from the darkness but from the consistent presence of guys in hooded sweatshirts moving along the sidewalks. Occasionally I would lie awake and hear scuffling and shouts, sometimes followed by a siren. Arriving home from school during the day then work at night, I had my keys out before I left my car. I checked my surroundings then walked with a steely presence to the front door. Checking behind me, I unlocked the door and quickly shut it behind me. My behavior never changed but over the years I spent there, I grew to feel safe. I was never approached on the streets, nor were any of my neighbors.

From the start my schedule was busy and I guess that’s why it was a few months before I saw the women on the corner. It was dark but they were gathered near a streetlight. One quite tall, the other two of average height. Despite the cold mist that covered the city, they were each in tiny shorts and skimpy tops, tops that pushed the flesh of their breasts over the minimal material that covered them. And heels. It was the heels that got me. I knew the sidewalk was full of holes and cracks. How did they not stumble? One of the women was cupping her hand around a lighter while the other two watched any car that slowed. Which mine did as it was where I needed to turn. But they only glanced at me before turning back to watch approaching cars.

While it heightened the edginess of the neighborhood, the ladies intrigued me. My apartment had large windows, and I often arrived home late and stood at the window and watched them watching the slowing cars. As a car stopped the passenger side window would lower, and one of the women would approach the car and the open window. Within a minute she would open the door and slip into the car.

Years before and in a different city, I worked with heroin addicts in a drug treatment clinic. There I met women who had been sex workers for years. Initially intimidated, I soon learned they were resilient women in unforgiving circumstances. They had survived things that would have killed me. I admired them for that.

Once I noticed the women, it seemed like I saw them everywhere. One day on the bus, one of them sat across from me. Her buttocks were tucked into the curved seat, her make up liberally applied. She was young, maybe not even eighteen, and her make-up made her look childlike. She boarded the bus like any other worker.

Then one day I saw the childlike woman again. I was at the laundromat behind my apartment building, and I was waiting for my clothes to dry. I wandered outside into bright yellow sunshine and paced the parking lot. I noticed a white pick-up truck in one of the end spaces, a large white man sitting in the driver’s seat staring out at me. Then that childlike face popped up from his waist and down again, and up and down. That man never took his eyes from mine.

In my second year in the city, because of the prospect of double overtime, I stayed in town for the Christmas and New Year holidays. On Christmas Eve the clinic was unusually quiet. An hour into my shift, I was already restless. When the police arrived with a street kid who threatened to stab himself, I grabbed the case. The police said he stood in the middle of a street, screaming, holding a large knife to his chest. “This was after the girlfriend said she was leaving him,” the cop added.

The police liked us. Mostly because they didn’t have to wait around when they brought someone in. They filled out a single piece of paper to put the person on a psychiatric hold, told us the story as they knew it and were back out on the streets. We were not legally bound to hold anyone for those seventy-two hours. But we were responsible for evaluating them for safety and the need for inpatient treatment. We usually sent more than half the patients placed on holds to outpatient care, rather than hospitalization.

I liked the job because the nurses had a lot of responsibility. And a good bit of respect. We always had a doctor, but we did most all the initial assessments. Which we then reviewed with the physician before we made a final plan. The challenge was in doing the assessment well. If you didn’t get the right information, if your report to the doctor was full of holes, and if this happened consistently, you would find yourself in a supervision session with the head nurse or the clinic director.

The young man is nineteen and the girlfriend is about the same age. His clothes are dirty, and he looks like his last shower was months ago. The girlfriend is better dressed. If she is living on the streets, she hasn’t been out there long. The clinic is so quiet, I talk with them for over an hour. The girlfriend is now being supportive. He wants to be released, and she is saying she will stay with him to keep him safe. I believe her promise to keep him safe is sincere, but I know, once back on the streets, the situation might change. Later I will regret not taking her aside and talking to her alone. From the beginning I know the safest thing is to send the girlfriend out and keep the young man at least until the morning. Had we been very busy, had the patients been piling up, I would have done exactly that. And no one would have questioned the decision.

Instead, I leave the kid with his girlfriend in a room. Meanwhile I see another patient who I know from the initial report I get will not take long. Then I return to them. He will be safe; she will stay with him. But I still am not sure. I have them sit longer. After he has been with us for a few hours and after multiple conversations with him and his girlfriend, I finally talk to the doctor about letting him go with a follow-up appointment the next day.

Christmas morning the quiet atmosphere is gone, and the place is full. The nurse holds a chart out to me. “By the way,” she says, “that kid you saw yesterday, he is in the OR, his girlfriend left him around midnight, and he stabbed himself in the chest. It was touch and go. But he’s going to live.” She’s still holding the chart she wants me to take. She pushes it toward me and says, “This woman came in on her own, brought a whole bag of meds with her, says she was afraid she was going to take them all.” When I still don’t take the chart, she starts waving it up and down.

Eventually the loneliness I felt when I arrived in this city begins to fade. It helps that I am busy with graduate school and my job. And I now go to occasional parties or hikes with friends, or even on a few dates. When the man I left behind in the old city calls me asking if he can visit, I say yes. Even as I know our relationship is unalterably fractured by his consistent infidelities.

When he arrives, we walk the bustling streets of the city, stopping in museums and exotic coffee shops. My biggest joy in this new city is the unending bulging bookstores; many of them small store fronts that tunnel into the back where I lose time among the tightly packed shelves. He is less obsessed with books than me and I am surprised when he follows me into these places without complaint.

This man broke my heart over the years I lived with him. For years he promised to change. And he would. For a while. Then the hang-up phone calls or unexplained absences would resume. We would break up. Then he would call, and I would go back. Moving stopped all that.

On his visit, neither of us talks about these things. Instead, we talk about art and history and the rewards of reading great literature. We explore the pretty parts of the city. The museums, the grand hotels, and the waterfront. I tell him about my new life here, using vignettes and interjecting color and in that telling, I discover a new story. A different narrative that is not fiction yet not fully true. It sounds more like the adventure I expected. My place of work and the stories I tell sound intriguing. I describe the schoolwork, which I find tedious, as if it is energizing.

I don’t tell him that I have struggled to find friends here. Or that I am still over eager for letters from old friends. When his departure approaches, he tells me he wants me to return to him when I have finished school. I tell him only that I enjoyed his visit. I don’t tell him that I wonder if the warm feelings I once had for him will ever return.

When he leaves, I return to my work/school schedule. One evening I talk with a woman who reports she is suicidal. She, like me, is single and in her late thirties. But her life is in ruins from serious past traumas. They haunt her. It is still the age of paper charts and hers is stuffed with emergency room visits and hospitalizations. None of the interventions have helped the deep depression she carries. I sit in a room with her, the thick folder of her troubles on my lap. She is so small. Her short brown hair circles her head like a halo. She pulls her body tight to the center of her being and only speaks if I ask her a question.

She had taken more than one overdose in the past few years and has also, on occasion, cut into her veins hoping to hit an artery. When I asked her why she has come in, she tells me she wants to walk into the mountains outside the city with no provisions or equipment. “They’ll find me in the morning, frozen to death,” she says.

Quietly prodding her I get mostly shrugs. As we talk, I realize her plan has minimal definition. She wants to wait a few months when the weather will be colder. But I remember the boy I let go into the night when he convinced me his crisis was not imminent. I tell the woman she should stay overnight in the emergency room, even though I know she will be released to outpatient care in the morning.

Six months later, I learn that she has killed herself. Not that time and not before coming in to see us several more times. Nor did she walk into the woods. Instead, alone in her apartment, she took another overdose.

Soon I begin thinking about moving from my neighborhood. I check out a place in a vibrant neighborhood in the city. It’s the downstairs of a house. Another studio but one with access to a small grassy backyard. It’s a block off a boulevard busy with quirky stores, coffee shops, bookstores, and neighborhood restaurants. No hooded figures, no women strolling the streets in small tight shorts and high heels.

I am considering renting it until, as I leave, I study the limited street parking. I think about arriving home at midnight and circling the blocks looking for a parking space. As I drive home, I wonder how I would fit the move into a schedule that has no room. It’s dark when I get home. I pour a glass of wine and stand at the window and watch the women. A car pulls in right below me and I watch one of the women briskly walk up, speak to the driver through the open passenger window, then swing the door open and get in. I want to stay at the window to make sure she returns safely. But I am too tired.

Each evening, I listen to patients whisper of childhood abuse and neglect and tell life stories fragmented by mental illness and drugs and alcohol. I watch the nurses who feel the sadness of those they try to help. And other nurses who grow cynical and speak briskly to clients who stop their meds or become unstable because of drug use. I worry about myself and compassion fatigue. Sometimes coming into work, I see only the litter beneath the benches outside the emergency room or the thick dirt that lines the curbs around the hospital. Inside I watch the housekeeping staff swish their mops across those old floors wondering if their hard work only serves to move the dirt around.

The hospital is in a poor neighborhood, but it doesn’t lack vibrance. It is full of bodegas and cafes, and dark daytime bars and ethnic restaurants. On the sidewalks women hurry along with kids, all of them carrying plastic grocery sacks. They quickly pass the alleys and ignore those who exchange money for small packets of powder.

The graduate school, part of the large university, several miles away, is a mass of tall white buildings scrubbed clean by the sun. In the nearby neighborhoods the apartment houses and small but expensive homes are inviting but pricey. Inside the school I sit for hours in softly lit classrooms and listen to theoretical lectures on the practice of nursing. There is no dirt and no talk of hooded characters or messy lives or prostitutes.

One evening I am assigned to evaluate an angry man in restraints. He is thin and wiry and yelling in Spanish. We have seen him many times. His wife waits outside the seclusion room. She speaks enough English to tell me that her husband came after her with a carving knife. She ran to the bedroom, locked the door and called the police. Last time it was a machete. The machete is no longer in the house; her son has removed it. “Off medications,” she says to me. Alcohol or drugs, I ask. She shakes her head. New medical problems? Once again, she shakes her head.

He is vigorously fighting the restraints and will exhaust himself if we don’t get him calmed down. I put my hand on his arm to check if his temperature is significantly elevated. Then I use a stethoscope to count his heart rate. Even with all his fighting, first with the police and then with us, his heart rate is not bad. I ask the orderly to stay with the patient. The orderly is younger than me. He is round and often morose.

I call the patient’s outpatient clinic and confirm what his wife had told me. I talk to our doctor and then draw medication into a syringe. The orderly did not stay with the patient as I had asked. He is outside the room near the main desk. He is trying to keep one eye on the patient and one on the television set mounted on the waiting room wall. When he sees me, he goes back into the room. I keep the syringe with medicine down by my side and out of sight. In my other hand I have a paper cup with the same medicine.

“Mr. R, we want you to take some medication, will you take these pills?” The doctor has come into the room with me. He tells the patient we want to help him calm down. The patient responds with shouts and grunts and thrashing limbs. Then he tries to kick the orderly, but the restraints do their work, and he is unable to reach his target. He aims his leg at the doctor but again he misses. The doctor and the orderly turn the patient on his side, and I quickly insert the needle pushing in the calming medication. When they lower the patient back to the thin mattress, he looks right at the orderly and once again thrusts his foot toward him clearly trying to kick him in the groin. Again, he misses.

“Mr. R.,” I say. “We are going to admit you upstairs.” I turn to leave but not before the orderly places his hand on the foot that tried to kick him. Looking first at the patient and then at me, he twists the patient’s foot. Then he walks out of the room.

I should report him. Or minimally, I should talk to him. Instead, I give into the hopelessness of doing this job well. I have been here too long. And I am always tired.

I go home that night and stare out my window. There are two women on the corner. One of them is the woman I saw get into a car months ago. The one I thought I should watch for a safe return. I know, with only six weeks left in this job, I am not going to report the orderly for twisting that patient’s foot. Knowing this disturbs me. I will be finished with school in a month. A colleague has offered me a job in the state where I used to live. My plan is to quietly leave this place.

I am surprised when my resignation garners much attention. There are several small gatherings and an official going away party. The clinic director asks to meet with me, and we talk about my years in the clinic. “It’s a challenging and demanding place,” I tell him. I think about telling him about the orderly, but it’s too late. What can he do with my report if I am out the door? And I know he knows anyway. We all know what happens. The good, even sometimes great work, we do and the rest of it too. I brought up the kid I released who left and stabbed himself. “If the clinic had been very busy that night, it would have never happened. I would have made the quickest and safest decision. But I had so much time with him. I really thought I could trust the two of them.” He nods.

The man I left behind calls and offers to help me move. I accept his offer. But I have no illusions about him. I pack up my apartment on my own. When he arrives, we drive to the U-Haul place. They attach my car to the tow piece. I’m glad I don’t have to drive an oversized truck on my own. I carry down the less heavy items, but my man friend does most of the work.

Many times, I have regretted coming to this city. But I have learned things here. Four years working with patients in crises have sharpened my clinical skills. More importantly, I have learned that intense work settings can erode the compassion that is just as important as nursing skills. While I have made friends who will stay in my life, I now realize that fresh starts are at times, an excuse for running away. I wonder about all the decisions we make in our lives. How one stacks up against the next.

When we finally pull away, I have an impulse to say goodbye to the women on the corner. And I do, silently, as we pass by them. A few minutes later we are on the freeway.